CENTER FOR INTEGRATIVE GASTROENTEROLOGY, PLLC

FULL NAME

ADDRESS

APT

CITY

STATE

ZIP

MOBILE #

HOME #

DATE OF BIRTH

MM/DD/YYYY

Email address

GENDER

MALE FEMALE PREFER NOT TO SAY

Which service are you interested in? Check all that may apply.

Microbiome

Gastric Alimetry

Elemental Diet

Were you referred by a provider ?

Yes No

The referring physician must be informed that they are responsible for reviewing all Alimetry test results with you.

By checking this box, you understand and confirm that your referring physician will receive the results and they will review all test results with you

Please provide your Referring Providers Full Name, Clinic Name, Full Address and Telephone Number below.

Attach Referral Here

Add file

Please upload a file

Self-referral is not accepted at this time.
An initial consultation with one of our physicians is required before proceeding with Gastric Alimetry testing. Please continue below to request an appointment, or contact our office directly at 212-734-3000.

Do you wish to schedule an initial consultation with one of our provider?

Yes No

Please indicate your appointment preferences below. A member of our team will contact you to schedule your initial consultation with one of our providers.

Please note: At the Center for Integrative and Gastroenterology, we are a self-pay practice and do not accept insurance. All services are out-of-pocket expenses.

Have you had a microbiome test performed before?

Yes No

If yes, please provide details (e.g., provider, date, or results if available):

What Our Microbiome Program Provides

Our Microbiome Program is built around advanced microbiome testing, but it goes much further. You receive:

Expert physician oversight throughout your care
Scientific analysis of your microbiome with trained medical providers and microbiology experts
Custom probiotic and prebiotic formulations designed to restore balance in your unique microbiome
Nutrition guidance tailored to your microbiome profile
Six months of structured follow-up, including adjustments to treatment, and direct access to our team to discuss your progress, symptoms, and lab results.

Consumer kits cannot offer this level of clinical insight or follow-through. Our approach is more effective and far more meaningful when it comes to your health.

Which Microbiome Service Package were you interested in?

6-month Plan

6-month plan | $4,800 | Includes: Initial evaluation 2 microbiome tests with comprehensive analysis Up to six (6) months of custom probiotics Up to four (4) months of custom prebiotics (2 formulations) . Plus, Ongoing support from our providers, from beginning to end

Add-on Service

3-month add-on | Additional Cost | Includes: 3rd microbiome test with comprehensive analysis for up to nine (9) months of custom probiotics Up to six (6) months of custom prebiotics (2 formulations). Plus, Ongoing support from our providers during the process

Elemental Diet

The elemental diet is a medical protocol prescribed for certain gastrointestinal conditions including small intestinal bacterial overgrowth (SIBO), and irritable bowel syndrome (IBS), among others. The diet consists of a liquid formula of complete nutrition broken down into its most elemental form and should only be administered under medical supervision.

This carefully formulated diet provides essential nutrients in an easily absorbable form, allowing the gut to rest and heal while maintaining adequate nourishment. By reducing the burden on the digestive system, the Elemental Diet can help alleviate inflammation, rebalance gut bacteria, and support overall microbiome health. Our expert-guided approach ensures that each plan is tailored to your specific needs, with ongoing medical supervision to maximize effectiveness and long-term benefits.

Are you currently pregnant or considering pregnancy within the next 3 to 6 months? If yes, you may not qualify for the Elemental Diet

Yes

Do you have a prediabetes or diabetes diagnosis?

Yes

Which Elemental Diet plan where you interested in? Please Only Select One (1)

Elemental 4-day Diet Plan

$950 | Includes: Initial evaluation with blood work, 4-day supply of elemental diet powder, 1-follow-up visit, and additional blood work if indicated. Plus, Ongoing support from our providers during the process.

Elemental 1-week Diet Plan

$1250 | Includes: Initial evaluation with blood work, 1-week supply of elemental diet powder packets, 1-follow-up visit, which includes an ECG, and additional blood work if indicated. Plus, Ongoing support from our providers during the process.

Elemental 2-week Diet Plan

$2250 | Includes: Initial evaluation with blood work, 2-week supply of elemental diet powder, up to 3 follow-up visits, which includes an ECG, and additional blood work if indicated. Plus, Ongoing support from our providers during the process.

Elemental 3-week Diet Plan

$2550 | Includes: Initial evaluation with blood work, 3-week supply of elemental diet powder packets, up to 4 follow-up visits, which includes an ECG, and additional blood work if indicated. Plus, Ongoing support from our providers during the process.

Please note: If any outside lab work is needed, it’s not included in the fees listed above and may be billed to your insurance separately. You may be responsible for any out-of-pocket costs, which would be handled directly between you and the lab.

Gastric Alimetry

Gastric Alimetry is a non-invasive diagnostic test designed to help identify and understand disorders related to stomach function. The procedure involves placing a sensor patch and a small recording device on the skin over the abdomen. Using advanced Body Surface Mapping technology, Gastric Alimetry measures the electrical activity of the stomach in real time.

The data collected provides detailed insights into stomach function, helping clinicians identify patterns that may be associated with various gastrointestinal symptoms. Once the test is complete, a comprehensive report is generated and reviewed by our clinical team.

Important Information:

Duration: The procedure may take up to 6 hours to complete. For this reason, it is only available during morning appointments.
Insurance: Please note that this is a non-covered service and entity. We do not accept or bill insurance directly, and payment is required at the time of service.
If you have any further questions regarding this service, please contact our office at 212-734-3000.

Preferred Appointment Time?

AM PM

Please note: A deposit may be required at the time of scheduling. This deposit will be applied toward your service package if you choose to proceed, or toward your consultation if you do not.

We kindly ask for cancellations to be made at least 48 hours in advance. Failure to do so may result in the forfeiture of your deposit.

Comments

Signature

Type your full name for your digital signature

Today's Date

Your information will be encrypted.